Writing with Scissors is the blog site of Howard Rodenberg, MD MPH, former Kansas State Health Director and columnist for the Journal of Emergency Medical Services (JEMS). He is a father, emergency physician, and slightly-past-fifty curmudgeon with great hair for his age. The "scissors" in question refer to those used by editors to weed out all things opinonated, controversial, or politically inappropriate...translated as "anything funny."

Thursday, June 30, 2011

I work in an area where there’s lot of hunting and fishing, so I’ve become familiar with the “seasons of the kill.” Right now it’s between seasons in the field, but within the ER Bug Season is in full swing. Bug Season is that time of year when bugs wander into people’s ears and people wander into my domain wanting the bug out. It’s something that’s unique to early summer, and all I can figure is that the bugs, attracted to the porch light on a summer’s evening, suddenly realize they’re gravitating towards the Bug Zapper of Arachnid Doom and think better of it, ducking into the nearest dark spot they can find, knowing full well that if they think twice about it they’ll finish that run to the afterlife. (See Marty Robbins, “El Paso.”)

Those whose ears have been used as insect refuge usually drift in about two in the morning. I’ve never had a bug in my ear (other than the metaphorical one), but it seems to be one of the most excrutiating things imaginable. The skin of the ear canal is paper thing and loaded with nerve endings, so the motion of the bug causes severe pain. In addition, the wafer of skin cells lies directely on top of bone, and bone conducts sound better than air. So every little flicker of the bugs legs or wings is not only felt, but heard as a loud, interminable grating noise. So when you consider that the bug is susally still alive, feet and feelers looking for traction and wings beating against the eardrum…you can get a sense of why getting the bug out constitutes an emergency that even I, with my low tolerance for anything less than an actual acute illness or injury, would recognize as worthy of an ER visit I the wee small hours of the morning.

There are a couple of ways to do this. One is to try to wash the bug out. This usually never works, as most people have already tried it at home and if the bug was dead, it came out. They’re in the ED because the bug, having tenaciously fought the deluge, is still thriving, damper but cleaner. So you have to kill the bug, and the best way is to drown it with some kind of oil of a solution of viscous lidocaine, a thick local anesthetic gel that you squirt into the ear canal and let it sit for ten minutes or so. Then you try to irrigate out the ear again, but this time using an IV catheter and a syringe in order to get a high-pressure blast of water in there. With any luck, the bug pops out. You hope it does, because the expectation from the patient is that you will then dig in the ear for the bug. You try to talk them out of this because a) it’s painful, b) it never works, and c) you’re just going to send them to an ENT guy the next day who actually has micro bug-out-of-orifice stuff in the office. The patient will want the bug out now, so you make a couple of half-hearted blind stabs (we don’t have the kind of ear instrument or scopes that allow you to look in the ear canal as you’re working, nor tools fine enough for the work), which results in more pain and quite likely a little bit of oozing of blood form the ear as you scrape the inside of the canal. You apologize profusely, show the patient whatever you’ve gotten out of the ear (a feeler, a leg, a bit of wing, a strangely shaped piece of wax) to demonstrate some progress, tell them that all bleeding stops eventually, and refer them to the ENT guy on the morning. Which is, of course, what you wanted to do in the first place.

Sometimes bugs beat the odds, and are just slowed enough by the attempted drowning to be flushed out, but still able to make a valiant attempt to get away once they’re back in the light of day. They pop out of the ear canal into a basin of water, often in tatters, their little feet struggling to bring them up for one last breath. It kind of makes you feel for the bug, as you witness their last gasp of buggy life. I was watching this Mutual of Omaha Wild Kingdom struggle for survival and remarked, in what I thought was a fairly deep moment for someone who had eaten nothing but six Hostess Twinkies, three Cokes, and a piece of Hampton Inn Free Breakfast Sausage in the past 36 hours, that the poor creature was “drowning in the waters of his own despair.” So for some reason now all the post-ear bugs in the ED are called “Howard Junior,” and I’m wondering if it’s time to start saying Kaddish for them. But given the way I long to have things named after me, I hope it sticks no matter what the bug’s personal faith tradition might be.

Tuesday, June 28, 2011

I’ ve always hated the abortion debate. It’s a difficult topic, involving morals, medicine, individual autonomy, and the law, and there is just no way to simplify the issue and have any kind of learned debate. But since learned debate has been expunged from our public discourse, abortion is now framed in labels and sound bites. You’re either pro-life or pro-choice, which I think are terrible labels for both both sides. Abortion is always a bad choice that may, at times, be considered necessary for a variety of reasons, but always a bad choice. And everyone should be also thought of as pro-life, in that we should want the best outcome for all parties involved in this most difficult decision.

With this in mind, I noticed recently that Medicaid officials have ruled that an Indiana law which pulls all state funding from Planned Parenthood to be illegal. As I understand the situation, Medicaid rules prevent service providers to be excluded from participating in the joint State and Federal Medicaid program based the range of services performed by the provider. Planned Parenthood performs abortions, but also provides other services such as family planning, cancer screenings, and care for sexually transmitted diseases. Medicaid can be excluded from paying for specific procedures such as abortions, but the entire agency and all the other services it provides cannot simply be struck from the provider rolls.

What bothers me specifically about the Indiana law, and similar bills passed in many states (one was proposed by Congress as well) is not it’s legal status…that’s up to the courts to decide. What annoys me is that it’s yet another example of how the exercise of partisan politics actually impedes the stated goal of those same Demagogues of Democracy.

Planned Parenthood does perform abortions. They do so out of funds that are privately raised and fees paid by individuals for care. State and federal dollars granted to Planned Parenthood are already prohibited by law for use in support of abortion services. Instead, they are used for family planning programs and screenings for breast and cervical cancer in underserved women.

So if we follow the money, we find that defunding Planned Parenthood as a political statement against abortion won’t affect abortion at all. What does get affected are those activities that help prevent unwanted pregnancy. Decreased availability of family planning services means more unwanted pregnancies, more children in single parent households, more children in poverty, and (paradoxically) likely more abortions as women struggle to cope with the consequences of unexpected pregnancy. And if we are framing the defunding of Planned Parenthood as promoting a “Culture of Life,” doesn’t it make sense that this culture would want poor women to be screened for and get care for breast and cervical cancer in the early stages while these malignancies are still curable, rather than wait until the patient has advanced disease?

I’m not Catholic, but there a lot of things I admire about the Catholic Church. One thing I’ve always found impressive is that their theology is always consistent. Their steadfast interpretation of the Culture of Life sets them against abortions, artificial family planning, and the death penalty. But it also means promoting health, welfare, and social justice for all, as we are all precious creations of God. I suppose that in America, you’re only precious if you can afford your own pap smears and mammograms.

Thursday, June 23, 2011

I have a pretty bad history with physical fitness. In fairness, I need to say at the outset that I’ve been blessed in that my life has had it’s issues, but one of them has not been a battle against weight. I was born a stick person, raised a stick person, and been a stick person my whole life. It’s not my Mom’s falt, either. While she only does two really good meals…Passover and Thanksgiving, both with all the trimmings…and she goes through phases like veal burgers and the ever-popular Sgt. Harriet’s Indiana Baked Chicken…it’s not like there were never brownies or Froot Loops in the house. I suppose it comes naturally, as my Dad was a stick person until he quit smoking in his 30’s. Since then, he’s become gradually more Santa-like, but I think he’s getting more jolly as well. So I’ve always known the weight was coming, but I’ve been fortunate to be able to avoid it until the past year, when thanks to the acute observations of my Cousin Sara the term “muffin top” has entered my vocabulary (and not in the sense that I wish it would have twenty years ago, when a muffin was a college girl and a muffin top was probably the sweater you were trying to talk her out of. Ah, memories).

As a result of my good fortune, I’ve always had a strange relationship diet and exercise. I’ve always been able to eat pretty much anything I want, and I’ll be the first to admit I’ve abused this privilege. It was at it’s worst during my public health years, the best way to get the attention of the STATE HEALTH GUY dedicated to HEALTH and HEALTHY LIFESTYLES was to present an idea with a couple of Hostess Twinkies in your hand. (I’ve since moved on. Now it takes a Suzy-Q, and in deference to the fine people in the dairy industry I chase it down with a glass of milk rather than the preferred Vanilla Coke. I’m just sayin’.) However, one of the great advantages to working in public health is the ability to justify things. So a single Starburst became a serving of fruit, and spearmint lifesavers became vegetables. Twinkies fell into the breads and cereals group, and were a way to show my commitment to the Kansas wheat growers as well as the petrochemical industry (I know the “cream filling” is actually plastic, but I do love it so.)

There is a downside of being a stick person, however. For me, it’s always been a healthy fear of the beach, the swimming pool, and short sleeve shirts. I look like Mac in the Charles Atlas ads on the back of the comic books of my youth, and he’s the one getting the sand kicked in his face. Slow dances made me nervous, because there’s nothing “hunky” for a girl to hold to. And with no upper body musculature, chin-ups and rope climbs in gym class were a nightmare. Most of my life I would have given just about anything to have another twenty pounds on me. So from time to time I would invest in a huge jar of “nutritional supplements”, mix the grainy powder in milk and drink the gummy residue four times a day. After three months I was able to pack on a whopping two pounds, and my Brother-in-Law, whom I actually like because he shoots, kills, and eats things and is my survival plan for the Zombie Apocalypse, laughed at me for trying. So that was the end of that.

I’ve had an even less successful relationship with exercise. From time to time I decide I need to work out. This usually goes well for a few weeks until boredom or pain (whichever comes first) sets in. Then l’m back to my sedentary ways for another year or two. Last year my try at fitness was to buy a Wii. I loved the thing, and for the first couple months of ownership I made sure to a seven game set of tennis every day as well as nine holes of golf. It was great while it lasted, but after six weeks I was still winded going up the steps. Since I live off instant gratification, I decided the Wii wasn’t working, so I shifted to Rock Band. (Note: Taking a top floor apartment with a cathedral ceiling so nobody’s living on top of you seems like a great idea when touring units. When a middle aged guy is dragging groceries up the steps? Not so much.)

The next step was to upgrade to Wii fit. This is a great program. Lots of exercises…cardio, yoga, and balancing work. I especially liked one of the later programs, where you had to sit quietly and unmoving for three minutes until an electronic candle burned itself to the nub. To me, this was the perfect exercise. Don’t move and get fit. And so I still do this exercise, sitting quietly on the floor for three whole minutes at least four times a week whether I need to sit down or not.

This year’s entrant into the fitness sweepstakes is going to be either P90x or the Shake Weight. P90x is the DVD-based workout program featured on late night TV, and it actually seems to work. However, it has started to fall in my estimation because it’s really hard, and my work ethic took the lottery money and is still off on vacation. In addition, a few months ago I saw a guy in the ER who had finished his first round of work and had managed to break down enough muscle tissue that we had to admit him to make sure all the newly-liberated proteins didn’t clog up his kidneys. I was almost as disturbed by the knowledge that his could happen to me as I was by the fact that he came to the ER in 30 degree weather wearing only black boxer shorts with pink and red hearts with a suspiciously open fly, sobbing while holding buckwheat pillow.

(As an aside, it was kind of funny to see how we addressed his issues. We gave him pain meds, of course…good stuff, not skimping…but he continued to whimper. At that point, we shift our internal paradigm for patient care from “poor, poor thing” to “buck up and get some balls.” Interestingly, we never ask female patients to “acquire an ovary.” No doubt a topic for further review.

Pain control is a controversial issue in emergency medicine, and in many states it’s become a political football as well. Most doctors feel they treat pain appropriately, while most patients…at least those who answer surveys… are convinced that they do not. I won’t claim to have any magic answer, or to be the perfect purveyor of pain pills and potions. A lot of it is still a judgment call based on how much pain the patient appears to have (do they look truly uncomfortable or not) and the degree to which the patient’s complaints of pain match the overall appearance. But I do have my own internal list of patients who can have whatever pain medicine they want without argument, no questions asked. You can have whatever you want if:

1) You have just broken a bone2) You have allowed me to put a clamp, knife, needle, or tube in any orifice, place or space it doesn’t normally belong. (Routine injections, IV's and urinary catheters excluded.)3) You have cancer.4) You are in a hospice.5) You have a toothache. (First visit only.)6) You ahve a kidney stone.7) You have a burn.8) Your care is delayed because the doctor you really need to see, like a surgeon, is either busy in the operating room or is “operating” at home, the local golf course, or the Hotel of Illicit Gratification, hoping that flash in the background was just lightning and not a camera phone.

These criteria stand in contrast to the patient I saw last week, who came in requesting a refill of her narcotic pain medication she had received for a rib fracture six weeks before. I had a chance to look at her records before I saw here, and in addition to her three previous visits for narcotic refills, she had a repeat x-ray that had shown the fracture to be fully healed. I told her that I would be happy to evaluate her, but that I was not going to be comfortable refilling her narcotic prescription for a fracture that was no longer there. At that point I become in turn, “The worst doctor I’ve ever seen, ”the rudest doctor they’ve ever had here,” and the guy who, "doesn’t understand that YOUHAVE TO GIVE ME WHAT I NEED, AND WHAT I NEED IS PERCOCET” Seeing I was not moving from my position, she refused further evaluation and left the ED. The sad part is that it took me longer to document the encounter, dictate addendum notes, and cover my bases from a risk management standpoint than it did to examine, diagnose, treat, and write up a woman who came in just a few minutes later with a life-threatening heart condition. But in this era where medicine is business, the customer is always right, and the ER doctor is nothing more that another disposable vendor of services, dissatisfied people complain and sue. Those who are truly sick are also those who value your care. But the whiners win out in the end, and that’s American medicine.)

So I’m thinking that if a really buff person can kill his kidneys doing P90x. and then cry like a girl about it, the last thing I need is to be dragged into the ED sobbing, my stick physique and my favorite pair of Justice League underwear on full display (although the fly does lie within a picture of Superman…heh,heh,heh). But as I am now the owner of a nascent “muffin top,” I need to try again. Maybe if I downgrade to something like L45q I could pull it off. Or maybe I can use the Shake Weight that they advertise on TV, because it looks like I can do that sitting down. And if I focus on my upper body, it’ll be good to have both forearms the same size again. My right forearm is about an inch larger around than the left, a permanent reminder of several years scooping Baskin-Robbins hard ice cream in high school. Of course, nobody thinks that’s the real reason one forearm is bigger than the other. For the purposes of dispelling that rumor, let’s just say that I dress left. And well.

Tuesday, June 21, 2011

There are a lot of annoying sounds in this world. The screech of fingernails on a blackboard. The thump thump thump of the three year old kicking your seatback in time to "It's a Small World" all the way to Florida. And the piercing wail of the EMS radio page an hour after midnight, just at the moment the ED is on the verge of being cleared out and the pillow...or at least a Jerry Springer rerun...beckons to your tousled head.

The call goes out on to an address on Castle Street for a middle-aged female with three months of vaginal bleeding. Several minutes later, we get report from the crew. The patient has only had vaginal bleeding for two months. So it's already 33% better.

Tonight's EMS squad pairs a man and a woman. I ask the distaff paramedic...who is also one of our Unit Clerks...for patient report. Specifically, I say "I've never had a vagina, so hopefully you can tell me why someone who has one that's been bleeding for two months would call an ambulance at 1:00 AM on a Friday night."

The paramedic smiles. "I suspect it has something to do with the alcohol."

Five minutes later, I'm in the room with both the patient and the vapors of her beverage of choice, so I ask. (I have to ask questions in the "why you're here NOW" category pretty often, so there's a set script here. Mine is not the best line. The best I've ever heard comes from my colleague Dr. John Prairie, who's version is, "And what MEDICAL EMERGENCY brings you to this LEVEL II TRAUMA CENTER this VERY NIGHT?")

"I know this is going to sound rude, and I don't mean it to, but what in particular brings you in to see us tonight after two months, instead of when it started or a month ago?"

"I was bleeding so much in the bathroom that they threw me out of the bar."

(I saw that one coming, but for some reason I can't explain just why. I know some people who think they have "Gaydar" or "Jewdar." Perhaps I have "Fibradar.")

Her exam is completely unremarkable...no bleeding to be found...and like many patients, it's going to take longer to do the paperwork then provide the needed care. So as I'm sitting down at the desk, I hear the nurse talking to the local domestic violence shelter.

"She wanted us to let you know she was here. Are her kids okay?"

Yep, she had left her kids at the domestic violence shelter to go out to a bar. And as the story emerges from the fog of war, apparently she's there because she has a stalker. Going to a bar is always a good way to shake them from your trail.

**********I go into Room 1 to see an older man who's been dizzy. As I start to ask him questions, his wife answers everything. This is another one of those situations where I've developed a standard script over the years. So I say, "Ma'am, I want your input, but I'd really like to hear from him how he's feeling, and then I'll want you to help fill in the gaps."

She blushed, and then the whole family started laughing. "I'm sorry. I always do that."

I asked the patient, "Do you ever get a word in edgewise?"

He shrugged. "Not often."

They seemed like nice people..fun people...so I decided to tell one of my stories. "You know, years ago I saw this little old couple when I was working in Florida. The guy was genuinely sick, but every time I asked him something, his wife would answer for him. And every now and then, when he would actually get out a word of his very own, she would put her hand on his head and say, "Shut up, Mohty. I'm tawkin to do dacotah."

They all laughed, so I figured I was on a roll. "She also wondered if I was Jewish, and if I was single. When she found out from the nurses that I was, she told me all about her granddaughter who was a college student and offerred me her phone number if I wanted to call."

I kept up the show for a good five minutes. Each laugh I got produced another joke or story. I was just on the verge of wrapping up my act by noting that I was there all week, and that you should tip the nurses and techs because they're working hard for you, when the patient finally piped up.

"Hey, doc...do I get to talk now?"

Two points for the patient.

**********We actually saved a life tonight. A lady came in with chest pain, as we're evalauting her she becomes unresponsive. She has no pulse and is not breathing. This is the kind of stuff we live for. Within moments she's getting ventilated with a mask, receiving CPR, and having sticky-backed pads placed on her chest to give her an electric shock. A few seconds later, voltage converts her heart rhythm from disorganized chaos to a normal rate with a bounding pulse and strong blood pressure. While the nurses prepare to start medication to stabilize her heart rhythm and control her pain, I step out of the room to call the cardiologist to take her to the cath lab. While I'm out of the room the patient's hearbeat again becomes unstable. By the time I run back to the room, the nurses have already given the needed shock and the patient is brought back to life once again. Total elapsed time of hands-on ER doc care: Fourteen minutes.

Another patient came in complaining of headache. She's had neck pain and headaches for years. She's been told the headaches are related to muscle tension, and she's had a compeletley negative workup, but she doesn't believe it. She wants them fixed now. She wants an MRI. I take her history, do her exam, write orders for pain medications, and check her response. I explain to her that in the ER, when the neurologic exam is stable we generally don't do MRI's. I explain it again. I painstakingly document the encounter and the areas of disagreement in the event that she chooses to bring it up the next day with adminsitration. Total hands-on ER doc care, not including observation time to watch for pain relief: Twenty-nine minutes.

I'm sure that says something about what actually constitutes an emergency, why saving lives takes seconds but risk management takes hours, patient expectations versus clinical realities, the problems with consumer-based health care, the silliness of a health care system that promotes equally silly behaviors, and the overall state of medical practice in America. But it's three in the morning, and I've got to see more chronic back pain and kids with runny noses who's crying is keeping up their parents and people who think they might have passed out yesterday but nobody was around to see it while I hope that someone else's grave misfortune will give me a purpose for being here.

I'll let you figure out the moral of the story, because honestly I'm just trying to make it to dawn.

Friday, June 17, 2011

Frank was brought in to the ER with a decreased level of consciousness. (Our technical term is "gorked.") According to the paramedics, he had called 911 and told them he might have had a seizure. (Decreased level of consciousness after a seizure is known as a "post-ictal state. The technical term is, once again, "gorked.")

It was a chaotic night in the ER. I saw 34 patients in the first 7 hours of my shift, and at times one might have to wait over three hours just to get into a room. This may not seem like a long waiting time when compared with a busy urban ER, but around here where people expect both a slower pace and faster service, it becomes a real issue. (For me as a physician, busy times mean more than just an increased workload. Clinically, the pressure to move patients through the system means less time upfront for patient assessment and less time for teaching at the end. Rises in workload also stress the decision-making process and add an extra element of risk to care. Administratively, it also means more patient complaints about delays, which are most often interpreted by hospital administrators as "the doctor's fault." That's not fair, because delays in care are most often related to the system as a whole...not enough beds, too many patients, not enough staff...rather than to the performance of any individual physician. But hospitals are loath to admit that their systems have issues. So the easiest person to blame is the ER doc, who is certainly more disposable than admitting or specialty physicians...translated as those who make money for the hospital...or even nurses who are in short supply. There's always another body with a medical degree out there to take the job, quality beside the point.)

Because there was no room at the inn, Frank got put in the hallway just catty-corner from the nurses’ station. As expected, he was pretty lethargic on arrival. There are two ways to wake somebody up, and they both involve what is politely referred to as "noxious stimuli." The first, and most elemental, is to simply yell at them. So I did.

"Frank?"

"Hey, Frank?"

"HEY, FRANK!"

Frank would wake for a moment or two, mumble off a few words, and drift back off to Frankland.

I ordered the requisite labs and studies, and resolved to check on Frank frequently in the next few hours. What I had not realized that my voice had gotten so loud and shrill with my repeated attempts that everyone in the ER now knew there was someone in hallway named Frank and, for some reason, the doctor was very interested in saying "HEY!" to him.

As mentioned, the ER was exceptionally busy. When we get that full, we open up some extra rooms in near the back of the ER that are usually used during the day for chemotherapy and other outpatient work, but can be pressed into service. The way leading back to those rooms went right past where Frank lay asleep in the hallway. So every time I went back there to work with those patients, I took the opportunity to stop by his bedside and shout, "HEY, FRANK!"

This eventually became our collective routine. Every time someone would walk through the back hallway, they would pause for a moment by the bedside and shout, "HEY, FRANK!" This got us to giggling, and soon we were simply looking at each other yelling,"HEY, FRANK!" a behavior that made perfect sense to us but utterly befuddled the poor nurse, not one of our ER clan, called in from home to help with the load. This frantic and frenetic Frankness was noted by a highway patrol officer in the ER at the time, who introduced us to some law enforcement versions of the other kind of noxious stimuli, namely pain. I'm not going to go into detail here other than to say I never thought you could do so much with two toes and an earlobe.

(Speaking of the highway patrol, the officer was here to interview three victims of a motor vehicle accident. They were a family-to-be who was rear-ended on the Interstate. The man was a tall, thin, and pale white with a wide variety of prison tattoos, including the requisite tear drops in the corners of the eyes, skulls surmounted by a flaming cross, and the letters L-O-V-E inked over one set of knuckles with T-R-U-B read over the others. The woman was a heavyset African-American, a good foot and a half shorter and two feet wider than her fiancée, who spent of the evening rocking back and forth in a chair whimpering, "Mama, Mama, Mama." The 15 year old daughter of the woman...the most normal looking and clearly the sanest of them all...also had the worse injuries, with broken teeth and nose. All you could do is look at the three and figure Love is Blind, There's Someone Out There for Everyone or some other simple plaudit because there's really no other way to describe the group.)

Frank did wake up about 4:30 in the morning, and turned out to be a pretty nice guy. He had no idea what had happened to him, only that he recalled having a sandwich delivered from Jimmy John's earlier that night. In a bold show of camaraderie with our patients, we had also received a delivery from Jimmy John's that very evening. It gave us something to talk about, and it turns out that Frank and I both like the Hunter's Club, substituting mustard for mayonnaise. They always say you bond best over food.

Wednesday, June 15, 2011

I’ve learned that in rural Kansas, frigid cold and high winds are the ER doc’s best friend. In a world where the entire health care system seems designed to drive you to the ED so “real doctors” can see paying patients at their own pace and get their beauty rest at night, weather is one of the few disincentives to convenience care. If you come to the ER on a night where the wind chill is 30 below zero (or degrees above absolute zero, if you like to know that sort of thing), you’re either really sick or totally bonkers, which is probably sick behavior in and of itself. (Indeed, you could make a case that to come to the ED for anything short of a near-death experience on such a night is clear evidence of suicidal ideations and mental illness.) It’s a little different in the city, where cold weather brings out…or in…the homeless for a place to stay the night and maybe get a stale sandwich and a cup of juice And while I can’t prove it, based on what comes in to the ER I’d suspect that police blotters swell during cold weather, as people get themselves arrested for minor offenses to ensure their “three hots and a cot.” (The more astute ones who know the system and have a severe allergy to the stainless steel found in handcuffs will complain of chest pain and rattle off a list of cardiac risk factors, virtually guaranteeing at least a 24 hour hospital stay. By the time they’re discharged, the police have completed their paperwork and have moved on.) But in rural America, these are the nights you dream of, the nights when you look around an empty department just before midnight and think, “Tonight I get paid for sleeping.”

The problem, of course, is that you don’t sleep. You walk back to the physician’s sleep room, and before lying down you move the phone close to your bed so you can answer it when it rings. And you know it will ring, but you don’t know when. So you sleep fitfully, tossing and turning, opening an eye every fifteen minutes like clockwork; and when the phone doesn’t ring after an hour or so, you get up and wander out into the department because you’re convinced that there’s something going on that you’ve missed. And it’s doubly difficult because you’re in the middle of an argument between your body telling you to sleep and your mind noting that you’ll only wake up again and feel even worse than before.

So what do you do when you can’t sleep? Well, I would like to say I use the down time to be incredibly productive, to write on my blog, to read the latest medical literature, to conduct in-depth research about why we’re worried about air traffic controllers who work one night shift every two weeks suffering from critical fatigue and falling asleep but why we’re perfectly okay with doctors, nurses, policeman, and firefighters chronically working at night or even 24 hour shifts. I mean, all these folks do is save lives. (The air traffic controllers will now get double coverage in the towers at night and a mid-shift nap. The aforementioned groups get nothing. Yep, I’m a little bitter.)

The truth is that the last four or five hours of a twelve hour night shift is spent in a special kind of limbo that reminds me of the drug ketamine. Ketamine produces something called dissociative amnesia; the patient is awake and conscious, but not responding to words or sounds. It’s really kind of spooky to watch. The eyes are open, the heart beats, the chest rises and falls, but they just lie still like you might see in a morgue. The best way to think about it is that the lights are on, but nobody’s home. From the view of the patient, dissociation means that there’s an awareness of something going on, but no way to figure out whom it’s happening to or how you might be personally involved. (To be frank, it's the same feeling I got chewing coca leaves hiking the high-altitude Inca Trail in Peru. I was fully alert, climbing, and interacting with the guides. And I could feel someone’s heart beating fast, could hear someone with quick, raspy breathing, but I had no idea that it was me.) When you work that back half of the shift in the early morning hours, you know something’s going on but you just can’t quite place it. You know someone is awake and that someone is tired, but you nonetheless slog on through the disembodied haze. Every now and then a patient in real danger will momentarily rouse you from your torpor, but despite what you see on television in real life those moments are few and far between. Frankly, it’s hard to get excited about chronic pain or a fussy child at 4 AM. It’s lot easier to care before midnight.

(I should note that some people do better with night shifts than others, and that there are real differences in biologic clocks. Shift length makes a huge difference as well. You can rotate your schedules to simulate a “physiologic workday” in eight-hour blocks and make an 11 PM to 7 AM night shift work quite well, but there’s nothing physiologic about 12 consecutive hours of continuous toil. Personally, I have always been much more of an evening and night person than a day shift guy. I truly find the hours between 7 and 11 AM painful to work, and on days off I tend to wake up about ten AM and go to sleep an hour or two after midnight. But even as a night guy I get tired about 3 or 4 AM, and that’s where the doldrums kick in.)

So you can’t do anything useful, and you can’t sleep. So you wind up doing that which is both not useful and not sleeping and burn a few more hours of your lifespan watching television. . (The one exception to the “time wasting” is on those days when I can watch Jerry Springer, which is always a useful exercise in Social Darwinism gone horribly wrong.) It gets to the point where you can plan your shift by reruns; it’s Home Improvement from 3 to 4; M*A*S*H from 4 to 5; I Love Lucy runs 5 to 6. Every now and then the cable channels will shuffle their lineup to keep you honest, but the only real problem comes on the weekends when the regular schedule changes. During those times, you rely on infomercials to keep you occupied, and while the schedule is less predictable after a while Chef Tony, the Magic Bullet Guy, aging pop stars from Time-Life, my med school classmate Troy Burns talking about vacuum pumps, and the gaggle of well-built women (my father would call them “deep breathers”) talking about “performance” become as familiar as Tim Taylor, Hawkeye Peirce, and Ethel Mertz. Here’s an example of how familiar these things can get: One of the “performance” programs features a very blonde and buxom PhD...specifically Victoria Zdronk, PhD, "Best Selling Author and Relationship Expert"...with a small mole on the inner upper aspect of her breast. That’s not unique in itself, but if you look closely you’ll see that every other shot flips her from one side of the screen to the other in a mirror image, including moving the mole from side to side.

(Incidentally, the first time I saw my friend Troy on TV, I sent him a Facebook note about it. Turns out he did a mock interview for the show as a favor for a friend ten years ago, and didn’t realize it was going to air in perpetuity. Turns out he doesn’t get any royalties, either by the airing or by the inch.)

TV time stops at 6. That’s when some of the more early-rising administrators start to poke their heads out of the sand, and one needs to be ready to respond to questions like “How was the night?” with totally politically correct answers like, “Any night serving the citizens of this fine community is a night well spent.” (Took a week to come up with that one. I’ve got more.) So I leave my little room, but on a brave face, and count down the last sixty sweeps of the second hand.

Speaking of my room, I’ve been spending a lot less time in it lately. This is because a few weeks back, an intoxicated patient who was waiting for a ride home went AWOL. This promoted a brief but vigorous search of the area, but by all accounts he appeared to be long gone. That is, until about two hours later when he was found dozing in the bathroom adjoining the ER doctor’s sleep room, pants down around his ankles, with a pool of what was suspected to be not-yet-digested burritos in front of him and a similar conglomeration of product in the bowel behind. Yes, my friends, he had managed not only to get into the doctor’s private office and to use to toilet, but also to both barf and fall asleep in the act of elimination. And while the room was cleaned by ED staff that night and again by housekeeping the next day, I refused to go in there until at least two days had passed I was sure that one of my colleagues had used the facility. I wanted to make sure there was a layer of trusted germs in between Mr. Elimination’s use of the seat and mine.

Monday, June 13, 2011

The Teen is at the age where he’ll make the decision when to go to bed, but still wants me to tuck him in. He is, however, supremely embarrassed when I give him a kiss on the head and say to him as I have every night we’re together for the past thirteen years, “Goodnight, best friend. “ I’m holding on to this as long as I can, because I know the day is coming soon when bedtime rituals will be a thing of the past, and that soon the basic hygiene practices of the adolescent male…that is to say, none at all…will make bedtime more of a wave-from-the-door kind of thing.I try to go to bed shortly after he does, in the hope that I can maximize my time with him by keeping our schedules somewhat parallel. But lately I’ve been working a lot of nights, so I’m having trouble shifting back and forth. The other night I woke up at 4 in the morning, having gone to bed at 10 the night before, and couldn’t get back to sleep no matter what. So I got up, paid a few bills, did some laundry and some dishes, worked on a few snippets for the blog, and still found myself unable to sleep two hours later.

So I started to play The Damn Game, otherwise known as Civilization IV. This is the same game that has been my blogging downfall the past two months, as noted in my piece “I Write the (Titles of) Songs” just a few days back. After a brief respite and a return to productivity, I’m back to The Game because the latest expansion pack arrived on Saturday, and I’d be remiss if I didn’t at least try out playing as the Portuguese.

It’s now about 6:30, and I hear the feet. These are the feet that, trained by years of knowing that on weekend mornings the father sleeps, know that this gives you several hours of computer and Wii time uninterrupted by parental requests to do things like “brush your teeth” and “eat breakfast at the table like a human being” and “let’s just have a meaningful conversation about what’s going on in your life because even though these moments bore you silly someday you’ll look back on it and value our time together.” The feet wake first, and as they hit the floor they send impulse to the hands to engage the power button, which then activates the eyes to open by the glow of the LCD screen.

(There has actually been some debate within our home regarding the actual timing of morning and when the feet can first hit the floor. My contention is that morning corresponds with the rising of the sun. His is that morning begins with the Rising of The Son. This dispute comes to head around those times when clocks spring forward and fall back. This leads to the invention of new time periods to describe the proximity to what I consider actually dawn, and thus delay his ability to engage the computer. Thus we have the Immediate Pre-Dawn, the Post-Immediate Pre-Dawn, the Pre-Imminent Dawn, The Imminent Dawn, The Post-Imminent Impending Dawn, Tony Orlando and Dawn, Dawn Wells as Mary Ann, and so until I run out of adjectives and yield the floor.)

On this particular morning, however, I’m at the computer first, my back turned towards his bedroom door. This causes the feet to hesitate, then shuffle. My unexpected level of consciousness is clearly a problem.

“Dad, why are you awake?”

“Couldn’t sleep. Got up at 4, couldn’t get back to bed.”

By the sound of his voice alone I can tell that the routine has been broken, and the spinning hamsters in his mind will need to come up with a new tactical plan. Like any strategy, adaptation needs with information.

“What are you doing?”

“Playing Civ IV.”

(Like he couldn’t tell by looking over my shoulder, which I know his doing by the smell of last night’s chicken curry and vegetable korma on his breath. I told him to brush last night, darn it, and when I checked his toothbrush was wet. He’s getting more clever by the day.)

He sighs and goes back into his room to read . Twenty minutes later, he’s back.

“Are you going to go back to bed?”

“Soon.” (I’m just about to send a few Portuguese knights in to knock off an Ethiopian catapult.)

My son knows me pretty well, so he knows that no matter how tired I may be I won’t vacate my game until I am assured of a win, know for sure I’m going to lose, or get a phone call from either Christie Brinkley or The Bride (not in that order). And thanks to the magic of DVD, he also knows The Big Bang Theory, which is our favorite show on TV. Sometimes he calls me Wolowitz, and sometimes I call him Sheldon. Because…well, we are.

So he decides he will solve the problem of the father being awake and potentially wanting to engage in conversation or other mutual activities that might interrupt his carefully planned morning of AdventureQuest, Neopets, and You Tube (he would direct you to “The Best Cat Video You’ll Ever See” or Parry Grip). So he adopts a strategy used by the character of Bernadette when she wants to get the socially awkward and quite literal Sheldon Cooper to get some rest after staying awake for three straight days.

“You really want to win at Civ?”

“Uh-huh.” (That’s one stubborn catapult.)

“You can’t do it unless you can think well. And what happens to our neuroreceptors when we stay awake to long?”

I look up at him, remembering the lines from the episode but not quite sure where he’s going.

“They don’t function well and they lose their sensitivity.”

“That’s right, Howard. So go to bed now, young man.”

I gazed at him, knowing that not only was he right but that this was the first step towards those days when he’ll be coaxing me to eat porridge from a spoon by making airplane noises. (Which, because I like airplanes, I will do.)

“Will you at least tuck me in and sing the “Soft Kitty” song?”

“I’ll give you Bob the Giraffe to sleep with and pat you on the head.”

Saturday, June 11, 2011

There's a young woman we see often in the ED. She has spina bifida and is in a wheelchair, and also has problems with migrane headaches and urinary tract infections. She’s' a pretty frequent user of the ER, but she's just so darn pleasant and easy to care for that we really don't mind.

Sometimes our familiarity with her makes us forget her disability. I'm sure that's what she would want. But I wonder if it she caught it when the unit clerk out front asked her to "Take a seat in the Waiting Room, and we'll be right with you," or when I said after finishing her care, "Let me do some paperwork, and we'll get you rolling." Ouch.

**********

While I wear black scrubs, and most male nurses and techs wear solid colors, women will often wear scrubs with different prints and designs on them to add a bit of color to their working lives. This is why one of the ER nurses was wearing a scrub top with a collage of squares from Monopoly. Given that I have no internal filter, it was a given that at some point...specifically 9:28 on a recent Sunday night...I would ask if it meant anything that the square for Community chest was located atop the left breast, while the one for Luxury Tax was over the right. No telling if there are any strategically placed "Go," "Chance," or "Go to Jail" spaces elsewhere in the print.

**********

We're able to hear the calls that go out from the County Dispatch Center to our local fire, police, and EMS services. Here are three calls out in the past week, literally transcribed:

"Medical Emergency. A woman says a light bulb fell on her head."

(Hearing this, one of nurse remarked, "It must have been a bad idea." She was transported to the hospital at her request, found to be exceptionally whiny, and discharged with alacrity.)

"Medical Emergency. Man is slumped over the steering wheel of his car beside the exit ramp."

(Turned out he was asleep, and none too happy at being awakened. At least when I sleep on the side of the road, I lean the seat all the way back so they can't see the body. If they think it's just an abandoned car, I'm not disturbed.)

"Medical Emergency. Man found unresponsive on the front porch. Pizza delivery found the patient, not sure if he was breathing. They left the pizza and called from a different location."

(There's a way to get free food...feign death. On arrival the EMS crew woke the patient, who refused care. He did not refuse the pizza.)

Thursday, June 9, 2011

I’ve heard that President Obama wants to raise taxes on the wealthy. Much to my surprise, it turns out I’m one of them. It’s not that I didn’t know my income. Every month when the bills are due I do the multiplication, (dollars per hour) x (hours per shift) x (shifts per month). Nonetheless, I had no idea I was wealthy. When I think of the wealthy, I think of folks playing golf and sipping cocktails at the club, living off investments and inheritances. I think of CEO’s and shrewd financiers; I think of Wall Street folks counting their cash, looking down on us from their penthouse views. I think of Robber Barons and Paris Hiltons, of reality stars, Bridezillas, and anyone named Kardashian.

When I think of the wealthy, I don’t think of a guy who’s pushing 50 and still working in an ER, mixing up his days and nights, spending more time in a Hampton Inn and eating instant oatmeal that in his own bed sipping a cup of tea served by a white-gloved valet. (The reality, of course, is that I make my own cup of tea, carry it to the bedroom, and then fight off the cat who just wants to share.) I don’t think of a guy who’s upside down on three mortgages and doesn’t want to default because of some antiquated sense of obligation (thank you, Wall Street…and you enjoy those record profits). I don’t think of someone living paycheck to paycheck with back taxes (from retirement accounts cashed in when the market first crashed…thanks again, Goldman Sachs); with child support and student loans still not paid off over twenty years after med school. I would be perfectly happy to be considered “wealthy” if I actually got paid for everything I do, but given that in some surveys half or more of all ED care is actually “given away” and not reimbursed, I am not so fortunate. And we won’t even get into the questions of liability I face for my actions, problems unknown to attorneys, investment bankers, or policymakers.

As a former professional bureaucrat, I really don’t have a problem paying taxes. What I object to is being labeled as “wealthy” and taxed at a higher rate simply to satisfy someone’s idea of class warfare. There is a clear difference between the “wealthy” who bust their butts to earn their keep, and those for whom the money simply rolls in. For the latter, a higher tax rate is a mere inconvenience; for the former, it’s a form of punishment, a clear message from the government about the value…or lack thereof…of hard work and effort. And the tax code is so convoluted that any sense of fairness is gone…it’s pretty clear that the “wealthy,” at least as I think of them, also have the resources to avoid the biggest tax bites.

But as my father told me some years ago, it’s not enough to have an opinion; you have to know why you think that way and what you would do about it. So here’s the Rodenberg Plan:

First, individuals are taxed at a consistent, graduated rate. The current numbers we have, with a top tax rate of 25%, works for me. Medicare, Social Security, and Medicaid taxes continue as a fixed percentage of income to a maximum rate. There are a minimal number of deductions, such that the tax code can be summarized in an hour-long Power Point presentation. Deductions can apply for dependents, mortgages, taxes paid to states, and student loans. There should be new deductions for those who pay child support and alimony; the recipients of these funds should have to pay taxes upon them as income. Other than that, your tax is your tax. Individual sate income taxes should follow a similar model.

(For the record, I think that if a piece of legislation cannot be fully explained to a lay audience in a sixty minute Power Point presentation…including cartoons and jokes…the legislation is too complex and needs to be thrown out.)

Second, corporate taxes should be based on a graduated but fixed percentage model as well. Tax credits or deductions could be granted for investments in infrastructure, employer support of employee benefits, or the creation of actual, filled jobs. Tax shelters in the form of offshore accounts and domestic loopholes need to be closed.

Finally, entitlement programs need to be means-tested. If I’m fortunate enough to live well in retirement, I’m willing to forego my Social Security payment as the dues I pay to have lived in an affluent society. I have a similar feeling about Medicare benefits; if I can afford my own insurance, I ought to do so rather than taking more money from the public purse. Again, it’s my personal sacrifice for the benefit of having been successful in life. And I believe that within Medicaid, services must be limited on the basis of medical necessity and cost-benefit ratio.

I think this plan has something for everyone. Democrats will like the emphasis or corporate taxation, and making the “wealthy” pay their own way rather than using public funds for a golf-centered dotage. Republicans will appreciate lower individual tax rates and a simplified tax code. Of course, special interest on both the left and the right will find reasons to trash these ideas, just as they will any ideas the real politicians may choose to propose. (This is assuming that the politicians don’t find reasons to trash each other’s idea first.)

Meanwhile, I’ll have to start learning to be wealthy. Maybe next time I drive through Kansas, I’ll rent the Full-Size Car rather than the Compact. And if only I could get the folks at the Hampton Inn to have room service…

Wednesday, June 8, 2011

Mr. Rowley was brought to the ER by his son for a drinking problem. Drink was no stranger to Mr. Rowley, nor Mr. Rowley to the bottle. He had been in a detox program in 2003 that had kept him sober for two years, and afterwards had been able to limit his drinking to a glass or so a day. But in the last few weeks he had lost his job, and the drinking returned in force, to the count of a couple pints each day.

I tend to think that alcohol brings out the real person under the everyday veneer, albeit it in an exaggerated form. That’s why every intoxicated person is different. Some are nasty and mean with a few shots in them; some get deep and philosophical, while others are funny and raucous. Some turn out to be just decent people, polite, respectful, who just seem to be drinking to numb the pain of the day. Mr. Rowley was one of those.

Mr. Rowley recognized his drinking was a problem, but he was not interested in detox; he figured he could do that on his own. What he wanted help with was the depression that led to the drinking. Not only had he lost his job, but also his means of support for the three children he loved dearly, as well as the ability to maintain his obligations to his ex-wife and to care for his pets. He felt he had nothing left, that everything meaningful to him as a man as caretaker and provider were being taken from him, and the only way out was suicide. He knew exactly how he was going to do it as well, at home in the backyard with his shotgun. (And being a man who’s been in similar circumstances in the past, I’ve known exactly how he felt.)

When someone states they have thoughts of suicide, and especially when they have a well-thought plan, they inadvertently trigger a set of clinical and legal interventions. Clinically, we make sure there are no medical problems which might be responsible for these dangerous thoughts. Legally, we are obliged to hold the patient in the ER for their own safety until evaluated by a mental health professional. If the psychiatric screener feels the patient represents a clear danger to himself, we are then obliged to continue to hold the patient for formal psychiatric evaluation. While larger communities often have a local set of mental health services, at the rural facility where I work that means transfer to the State Psychiatric Hospital an hour and a half down the road.

Mr. Rowley had made it clear that while he wanted help with his depression, he didn’t want to be admitted to the State Hospital. He wanted to get some therapy, maybe get on some medicine for his depression, then go out tomorrow and look for a job. But he couldn’t have realized that once the process is set in motion, it can’t be stopped. His statements to me meant that he needed psychiatric screening. His statements to the mental health worker mandated further evaluation at the State Hospital. The fact that he was under an involuntary hold meant that he would need secure transport by law enforcement. And knowing that he didn’t want to go meant that we couldn’t tell him what was going to happen, as if he knew he would leave and short of using force there would be no way to stop him.

So we ended up playing this game of buying time with sandwiches and sodas, telling him we wanted to make sure he was sleeping off his alcohol before letting him go, until all the arrangements had been made and the police were here for transport. It’s my job to tell him what’s going to happen, and I did so as softly as I could, for I felt for this man. Polite, reserved, dealt a bad hand in life, and about to be dealt an even worse one by policies and procedures far beyond his control or mine. He tried to negotiate, but there was nothing more to do. The die was cast.

So here’s this proud man, who is a likeable and decent citizen, getting escorted to the State Hospital by police, and not even with the last piece of cake we’d gotten for him out of the hospital kitchen. Short of going in handcuffs, it had to be the most humiliating thing we could have done to him. All of it was legal, and all of it was exactly by the book. And while I really hope we’ve done something good here, and gotten him some care that can help him find a reason to go on, I can’t shake this feeling that all we’ve really done is let him know that the next time he feels this way, asking for help only makes it worse. I wonder if we’ve made suicide a more inviting option, because at least you go out on your own terms. And I wonder if, as noted by Albert Camus, “There is but one truly serious philosophical problem, and that is suicide,” we’ve just helped him answer the question.

Tuesday, June 7, 2011

One of my favorite moments in political history was during the Nixon Administration, when an obscure Federal Judge named Harrold Carswell was nominated to the Supreme Court. In defense against charges that Carswell was "mediocre", Senator Roman Hruska of Nebraska (Republican, Nebraska) stated:

"Even if he were mediocre, there are a lot of mediocre judges and people and lawyers. They are entitled to a little representation, aren't they? We can't have all Brandeises, Frankfurters and Cardozos."

Given how our standards for public life have fallen in the past forty years, I suspect Judge Carswell would have an easier time of it today, at least as long as he believed whatever the current Chair of the Senate Judiciary Committee believed about abortion. But there was a nugget of truth in the good Senator’s statement. Given that a few of us are geniuses, a few are total duds, and most of us lie somewhere in the middle, perhaps we’d all be happier if we strove for the median instead of the top?

We’ve actually discussed this late at night in the ER, and we’ve come up with the following potential morale-building internal slogans:

“Striving for Mediocrity”“Defining Adequecy.”“We Aim for the Middle.”“At Least We’re Better Than Jetmore.”

I think there are lots of advantages to this kind if system. First, as we are a pretty decent hospital, we’re sure to meet our goals. There’s satisfaction in that. In addition, we know that third party payers and government agencies are always looking for outliers, and cast their investigative net accordingly. Being average lets you fly under their view. Finally, it’s the kind of thing that everyone can buy into, because we really are better than Jetmore. We think.

Monday, June 6, 2011

While I won’t claim to understand physics, I do appreciate the way mathematics is used as a constant, objective language to describe the universe. Therefore, you can understand why I’ve always been intrigued by ways in which human behaviors can objectively described by math. Until Hari Seldon comes along to develop the science of psychohistory, the world will simply have to limp along with my brief attempt at such an effort, a few musing which I have modestly termed Rodenberg’s Universal Laws of Inverse Acuity.

1) The severity of the presenting illness or injury is inversely proportional to the number of decibels generated by the patient in registering their discomfort or displeasure. If you’re able to exert that much effort at complaining, there can be very little going on sapping effort from your vigorous noisemaking.

2) The severity of the illness of any one family member is inversely proportional to the number of family members who have accompianied the patient to the emergency room, or to the number of family members to seen by the emergency physician for various medical problems during the same visit.

3) The severity of any one patient complaint is inversely proportional to the number of complaints exhibited by the patient at the triage window. If you are stable enough to think exhaustively about all the things wrong with you, there can be very little really wrong.

Friday, June 3, 2011

They say the title does not make the man, and that’s also true in medicine. There are plenty of people out there who are book smart but lack common sense, and some of them carry the title of physician. It's like the old joke about what they call the guy who graduates last in his medical school class. The answer, of course, is “doctor.”

I have an ego as much as the next guy, and I like to think that I’m a reasonably bright citizen. But I also like to think I know my limitations. I know, for instance, that despite reading the CDC guidelines I will not survive the Zombie Apocylaspe, as I’m fairly certain the ability to sporadically blog and complete paperwork for maximum reimbursement pales compared to the ability to kill your own food and build your own fortress. (This is why my son already has reservations to live his post-Apocylatic days with my sister and brother -in-law, who have these qualities in spades.) I also know that I have trouble keeping my shoes tied, like to drive in the left-hand lane, think recording ATM withdrawls in the checkbook is only an option and not a requirement , and am a relatively poor parallel parker.

So I’m fully aware that there are folks in medicine who are a lot brighter than me. That opinion isn’t based on what you might think, like who’s a “specialist” and who’s not. The truth is you get be a “specialist” not because you’re the best at what you do, but because you’re willing to slog away, overworked and underpaid, for umpteen extra years for others who, by dint of seniority and not by quality, have you to do their work for them. And it’s not that hard to become a specialist. If you’re willing to go anywhere, there’s always a training spot somewhere. (A significant reason that I’m an ER doc and not a plastic surgeon is simply that I didn’t want to get beat up for five years of general surgery and two or three more of plastics when I could sail through relatively unabused in three years of ER. A powerful work ethic has never been one of my strong suits.)

My personal view…and one, I suspect, shared by many ER docs…is that most specialists can’t work their way out of a paper bag. They are very, very good at dealing with the handful of things they do routinely (and at high cost). But you’d be stunned at the number of “collegial” phone calls I get from doctors wanting to know what to give their kids for a cold (“Tylenol” is always a good start) or what’s the best thing to do for a sprained ankle. In fact, that was one of the things that first attracted me to Emergency Medicine, as it seemed that ER docs were the only people left who actually knew how to do all those basic things you always thought a doctor…well, at least a doctor on TV…should do. Twenty-five years in, I recognize that was poor basis for a lifelong career choice, and I recognize that the inability of other physicians to take care of the simple things means there are an infinite number of reasons for “real doctors” in their offices with normal hours, the ability to control their workload, and the benefit of actually being reimbursed for the patients you see to use the ER as a convienent whipping boy. But the optimism of youth won out, and now I’m too old with too many mortgages to do something else.

One of the more pleasant discoveries of working ER in a more rural setting is that, in fact, there was a reason you were in the top half of your medical school class. Out here I’ve seen both the best and worst of medicine. There’s the best, because I truly believe that the single most difficult thing to do in medicine is to be a good family physician in a rural area. You’ve got to be able to manage the greatest spectrum of care with the least support, and do it to the same standard as the guy at a teaching hospital with specialty backup for each gonad. There are a lot of these unsung heroes out there, doing the right thing every day in a manner I can’t even approach. But there’s also the worst, as rural communities starving for medical care take whatever they can get, and sometimes it’s that guy at the bottom of his class who’s still called “doctor.”

The problem is trying to figure out how I should respond to the baboon (and, as Groucho Marx notes in “Duck Soup,” that’s an insult to the rest of the baboons) who calls in the middle of the night to transfer you a patient that either don’t want to deal with or they’ve clearly mucked up. Most of the time you grab the phone with righteous indignation, determined to spit out in no uncertain terms exactly what you think of their clinical skills and to suggest that they get a new job selling door-to-door ham, where at least the product is already beyond help. However, after a few seconds reality sets in, and you figure that at least the patient is better off at a hospital that knows what they’re doing (that’s a polite turn of phrase for “get them out of there before someone kills them.”)

Purists…basically those academics, policymakers, and ethicists who exist in a sheltered world…might say that when we come across these scenarios, it’s our duty as physicians to turn in our less capable colleagues to the State Medical Boards. But doing so doesn’t help hospital volumes, and less patients mean less revenues. Making your concerns known in the public record so that the other doctor’s referrals go elsewhere does nothing but get you relieved from your job. Sorry, but that’s the real world. No matter how justified or correct they might be, squeaky wheels in the employ of another get no grease. They get fired.

(Interestingly, while there are always better and worse physicians in a community, I don’t see the same breadth of quality of care in more urban areas. I’m not quite sure why that is. Perhaps it’s because physician practice groups are larger and there are more doctors to “ride herd” on one another, and because hospitals have medical staff and administrative structures to ensure the quality of care. When you’re the only game in town, quality…or lack thereof…is what you say it is, and there’s no one to argue otherwise.)

Needless to say, I’m not about to tell you which physicians I’m thinking of as I write this or what exactly they’ve done. I’m fortunate that at the facility where I work, we have a pretty good record of getting patients out of the hole dug for them by their own doctors. But I can tell you one story that just gives you a sense of some of our referrals.

A middle-aged male was sent to us for evaluation after an intentional overdose of Phenobarbital. Phenobarbital is used mostly as a medicine for seizures, and in large doses it can cause sedation. Management of these overdoes is actually pretty easy. Make sure the patient’s breathing okay, and let them sleep it off. This patient, however, became angry when aroused and started to swing at folks. So rather than simply letting him sleep, the doctor at the other facility decided he needed to be transferred to us. He was apparently loaded into an ambulance with difficulty. He was unloaded with no difficulty at all, because there’s nothing like the steady drone of tires on interstate plus a heapin’ helpin’ or barbiturates to induce a nap.

I checked him out, fully expecting to see what had been advertised…a guy who needed to sleep. What nobody had mentioned…and I’m giving the other doctor of the benefit of the doubt by saying they didn’t know enough to look, because to take the other tack is to call them a liar…is that he also had the snot beat out of him, with multiple abrasions and bruises all over his head and face. That’s a pretty good reason to be agitated, don’t you think?

A few x-rays later (the same x-rays I know they have at the other hospital), we were back to Plan A, and he was admitted to sleep off his mischief. Maybe the other doctor just knew our beds were better for therapeutic non-intervention. But I can’t fault the other doctor entirely for knowing the patient had a better opportunity for competent care at our place. This was proved later that night when he got mad about not being in his hometown ER anymore, and decided to roam about the room flinging chairs and pulling towel dispensers off the wall. The hospitalist on the case decided that the best course of action was to bandage his cracked and blistered feet.

You’re probably asking, as did I, why that was the preferred method of care. Was it out of compassion and understanding, a desire to build trust within the physician-patient relationship? Perhaps it was a show of humility by the physician, a bold statement of service with a Christian precedent?

Turns out she did it because it was smart medical care. With his feet wrapped in gauze, he couldn’t get any traction on the slick, freshly waxed hospital floors. So when he tried to get up, he’d slip back onto the bed. Sure, he could still yell, but hospital property was no longer in the air. It was a flippin’ brilliant move.

Thursday, June 2, 2011

A thirteen year old boy was playing on the banks of a local creek in his bare feet when he stepped upon a dead catfish. As you may know, catfish are so named because they share several qualities with their land-based counterparts, including “whiskers” on the front of their face and an utter indifference to the presence of humans, with the possible exception of when you throw some pellets into the water at a feeding pond. The “whiskers” are actually cartilaginous spines that stay moist and malleable when the catfish is alive and in the water. When the catfish has washed up on the bank of the creek and dried out a bit, the spines become small barbed weapons that tend to get stuck in things. Things like the unshod foot of a thirteen year old boy, who showed up at the front door of the ER with a catfish spine stuck in his foot. Which was, in turn, still attached to the head of the disembodied catfish.

Many people think of medicine as a delicate art. It’s not always. But it was worth the ol’ med school try, so I numbed up his foot and tried to gently remove the catfish head. I made a small incision at the base of the wound hoping to find room to free up the barbs so I wriggle it out with minimal tissue damage. This, of course, didn’t work. Enter the vise-grip pliers, a backward pull, and a lot or torque, which did.

The patient did well and is now home, having negotiated a stop at McDonald’s with his grandmother before leaving the ED.

The catfish head resides in a small specimen cup currently sitting on the desk of the ER Manager.

Wednesday, June 1, 2011

The Teen is going to Claymation Movie Camp this year, and since it’s his third summer in a row he tells me he’s going to be a Counselor-in Training, or CIT. Which reminded me that one of the nurses was having her 30th birthday a few weeks back, and she mentioned that she was going to be a puma. “A puma?” I asked, not seeing where this was going. “Yes,” she said, “a puma…a CIT…Cougar-in-Training.”